A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?
Disorientation
Anorexia
Increased anxiety
Blurred vision
The Correct Answer is A
A. Disorientation in an older adult after taking lorazepam could indicate an adverse reaction or an excessive sedative effect. It's crucial to report this immediately as it may signify an overdose or an adverse reaction to the medication. Older adults are more sensitive to the sedative effects of benzodiazepines, and disorientation can indicate potential serious side effects.
B. Anorexia (loss of appetite) is a possible side effect of lorazepam but is not typically considered an urgent or immediate concern unless it leads to severe dehydration or other complications.
C. Increased anxiety could potentially occur due to paradoxical reactions to benzodiazepines; however, it's not typically considered an urgent or immediate concern unless it's severe or distressing to the client.
D. Blurred vision is a common side effect of lorazepam and other benzodiazepines. While it should be monitored and reported, it might not be considered an urgent concern unless it's significantly affecting the client's ability to function or is accompanied by other severe symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.
B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.
C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.
D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.
Correct Answer is D
Explanation
A. Coolness at the IV insertion site is not a typical sign of phlebitis. Phlebitis often presents with warmth or increased heat around the vein due to inflammation.
B. Drainage at the IV site might indicate infection or other complications but is not a specific sign of phlebitis. Phlebitis primarily manifests as redness, tenderness, and swelling along the vein.
C. Pallor (pale coloration) at the IV site is not a typical sign of phlebitis. Phlebitis usually presents with redness or erythema due to inflammation.
D. Erythema (redness) at the IV catheter insertion site is a hallmark sign of phlebitis. It indicates inflammation of the vein where the catheter is placed and is a common early sign of phlebitis. Other signs include warmth, tenderness, and swelling along the vein.
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